Intake Form – AI Scottsdale Chiropractor

Please complete this form as accurately as possible before your first visit. All information is kept strictly confidential per HIPAA guidelines. Fields marked * are required.

Personal Information

Full Name*

Date of Birth

Age

Home Phone

Cell Phone*

Street Address

City

State

ZIP

Email Address*

Marital Status

Married Single Divorced Widowed

Occupation

Employer

Work Address

City / State / ZIP

Spouse's Name

Number of Children

Referred By (Doctor, Website, Friend, etc.)

Chiropractic History

Have you received chiropractic care before?

Yes No

Date of last visit

Is this injury or illness related to an automobile accident?

Yes No

Date & Time of Accident

Location

Auto Insurance Company

Phone

Third Party Insurance Company

Phone

Reason for Visit

What is the reason for your visit?*

If anything hurts, how long has it hurt?

When did these problems originally start?

Other Chiropractic or Medical Doctors consulted for these conditions

Payment & Policy

Due to changes in health insurance fees, payment is due in full at the time of service. We no longer bill insurance companies directly, which allows us to keep our fees lower for you. We provide you with a HIPAA-compliant, insurance-ready superbill which you may submit directly to your insurance provider, so that any reimbursement checks are sent directly to you.

All charges are due when services are rendered.

Preferred Method of Payment

Check Cash Credit Card

Understanding Your Care Options

Chiropractic care may help relieve pain, improve mobility, and support long-term spinal health. Some patients seek temporary symptom relief, while others pursue corrective care focused on addressing underlying causes.

Relief Care

Relief care is intended to reduce pain and discomfort as efficiently as possible, though symptoms may return if the underlying issue is not corrected.

Corrective Care

Corrective care focuses on improving spinal function and addressing the underlying source of symptoms for more lasting improvement.

Authorization & Signature

I authorize this chiropractic office to render necessary care and understand that I am responsible for all charges incurred.

Patient Signature*

Date

Parent or Legal Guardian (if patient is a minor)

I understand this form is not a request for emergency care and that my information will be kept confidential per HIPAA guidelines.

(602) 954-2447

Confidential Patient Information

Relief Care

Corrective Care